Androgenic Alopecia

Doctor Information

Patient Information

Jeremy Crafter 38

You are very concerned today, and have booked to see a doctor

You are a high flying salesman, who relies on his appearance and demeanour to sell multi million pound deals to other big companies. You are one of the best at it! Over the last few years, you’ve noticed thinning of the hair at the front, receding backwards up your forehead. This wasn’t too much of an issue for you, but now you’ve noticed a bald patch developing on the crown of your head. This is not something you wish to tolerate, you have concerns over how this might affect your ability to sell services for your company.

You've also entered into a new relationship recently and you have been very self conscious of your hair loss. you've even gone so far as to wear hats to almost every date you’ve been on! Luckily your new lass is shorter than you so hasn't noticed the hair loss. You’ve come today as you want some answers. You initially suspected this was simply a familial thing, as your father went bald in his early 40s. However you read online that stress can cause a different type of hair loss - something called alopecia, and you were wondering if this could infect be that instead? You don't feel that this is affecting your mood, you don't feel down, depressed nor hopeless.

You’ve not really looked into treatments much, but you feel that if we can cure cancer, surely there must be some good treatments out there for baldness in this day and age. You’ve seen great results with Wayne Rooney’s hair transplant, so if all else fails, you would like to be referred for this treatment (on the NHS if asked - as you pay a lot of taxes!)

You don't smoke, and drink the occasional alcohol. You go to the gym regularly to work out - you find it helps relieve stress. You have no other ongoing medical problems. You take no routine medications.

Ideas: that this is likely male pattern balding, but you wonder whether it could be alopecia?

Concerns: about how this will affect your current job and new relationship. Expectations: if there are no tablets or creams that will work, then you would like an NHS funded hair transplant operation.

If the GP is nice and explains everything to you (including that the medical treatments aren't always particularly effective), then you will actually take a private referral to see a specialist. You earn enough that you could afford it.

Examination Findings

Examination:

Norwood-Hamilton Scale: 3 vertex

Mark scheme

Data Gathering

POSITIVE INDICATORSOrganised and systematic in gathering information from history taking, examinationIdentifies abnormal findings or results and/or recognises their implications

Enquires about psychological effects, and enquires about mood.

Data gathering does appears to be guided by the probabilities of diseaseUndertakes physical examination competently

NEGATIVE INDICATORSMakes immediate assumptions about the problem Intervenes rather than using appropriate expectant management Is disorganised/unsystematic in gathering information Data gathering does not appear to be guided by the probabilities of disease. Fails to identify abnormal data or correctly interpret them Appears disorganised/unsystematic in the conduct of physical examinations

Clinical Management Skills

POSITIVE INDICATORSMakes appropriate diagnosisDevelops a management plan (including prescribing and referral) that is appropriate andin line with current best practiceMakes appropriate prescribing decisions - in this case particular case discussing options, and explaining side effects and efficiency of treatment. Explaining that no medical treatment available on NHS

Offers private referral

NEGATIVE INDICATORSFails to consider common conditions in the differential diagnosis Does not suggest how the problem might develop or resolve Fails to make the patient aware of relative risks of different approaches Decisions on whether/what to prescribe are inappropriate or idiosyncratic.

Follow-up arrangements are absent or disjointed

Inter Personal Skills

POSITIVE INDICATORSIdentify patient’s agenda, health beliefs & preferencesWorks with the patient to develop a shared management plan or clarify the roles of doctor and patientEmpathises with psychological effects of hair loss

Uses explanations that are relevant and understandable to the patientShows sensitivity for the patient’s feelings in all aspects of the consultation including physical examinationDoes not allow own views/values to inappropriately influence dialogue

NEGATIVE INDICATORSDoesn't enquire about patients ICETakes a doctor centered approach towards managementUses an explanation that is filled with jargon, or forgets to explain at allDoesn't show any sympathy / empathy towards the patient's situation

Management

Explanation:Male pattern baldness is the common type of hair loss that develops in half of men over 50, and most men at some stage in their lives. It usually takes 15-25 years to go bald from first signs of hair loss. However, for some men the process can be quicker, taking as little as 5 years. The hair begins thinning at the side and at the top of the head. A bald patch develops in the middle of the scalp. The thinning sides and bald patch get bigger, and eventually join together. A rim of hair is often left around the back and sides of the scalp. There are treatments available, however they are best thought of as trying to slow down the process, rather than reversing it. None of these treatments are available on the NHS.

Assessment:(Quoted from NICE CKS on Androgenic Alopecia:)

History:◦Timing and pattern of the hair loss:▪When did it start?▪Was it sudden or gradual?▪Where was it noticed most?◦Past medical problems, including systemic or endocrine disorders in recent months.◦Family history of hair loss.◦Use of medication / shampoos◦Dietary habits.•Ask specifically about the psychological impact of hair loss and the impact on quality of life.

Telogen effluvium: sudden / profound shedding of hair when it’s in its resting phase, usually triggered by life events, illness, stress etc.. Shedding occurs all over, rather than in one distinct area.

Trichotillomania: Deliberate hair pulling

Alopecia Areata: Inflammatory, usually relapsing condition which affects the hair follicles. Hair loss is usually patchy / circular in nature, although total hair loss can occur.

Management:

Do Nothing: For most men this is the preferred option.

Non Drug Treatment:

Hairpieces or Wigs (may be provided on the NHS)

Surgical Hair transplant - Not available on the NHS

Drug treatment options: (none available on the NHS)

Minoxidil 2% scalp solution

Minoxidil 5% scalp solution

Finasteride 1mg OD

None proven to be better than another, just down to personal preference. Results are frequently poor. A trial period of around 6-12 months is recommended. Any benefits will only be realised whilst maintaining therapy, once stopped rebound shedding can occur. Both options costly in the long term. Patients need not come to a GP for medication, as many pharmacies in large chains (Boots etc..) will often sell above treatments after an in house consultation.

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